Parent Questionnaire for New Patients - Rochester, NY

GOLISANO CHILDREN'S HOSPITAL

Developmental and Behavioral Pediatrics

Parent Questionnaire for New Patients

The attached questionnaire gives you a chance to tell us about your child. We want to know about your concerns and worries so that we can try to help. Knowing about things like your child's health, past experiences, and family history can help us help your child. The questionnaire should be completed by the person who takes care of the child most of the time. There is no right or wrong answer. Answer each question to the best of your ability. If you do not know the answer, make notes of what you do know. We need this form before we can schedule your child's appointment. It will be reviewed by staff at Developmental and Behavioral Pediatrics who will be involved in your child's care. When you talk with our intake team, please ask any questions you have while trying to complete these forms. Please also let us know about problems that were not covered on the forms. If you have questions about this form or have difficulty filling it out, please call our intake coordinators at (585) 275-2986. All information is kept strictly confidential. Once you have completed this form, please send it to:

Intake Coordinator Developmental Behavioral Peds @ E. River Road 601 Elmwood Avenue, Box 278877 Rochester, NY 14642 Fax: (585) 275-3366

601 Elmwood Avenue Box 278877 Rochester, NY 14642 585.275.2986 585.275.3366 fax golisano.urmc.edu/dbp

Child's name

Child's address

Child's medical insurance company

Persons Completing Form

Name

Relationship to child

Biologic parent Foster/adoptive parent

Relative Guardian

Biologic parent Foster/adoptive parent

Relative Guardian

Child's date of birth Date form completed

Other Other

Does the child live with you? Yes No Yes No

Phone numbers

(H) (C) (W)

(H) (C) (W)

Home Information Main language spoken at home

English Spanish American sign language Other:

Please list all adults and children who live at home with this child.

Name

Age

Relationship to child

Occupation or grade in school

Has this person ever been seen in Kirch/DBP?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Are there any living arrangements (for example, shared custody or foster care), custody issues, parental disagreement about care, or orders of protection that we should be aware of?

What is the reason you would like your child seen in this program? What questions do you have?

Has your child ever been diagnosed by a doctor or psychologist with a developmental or behavioral disorder?

Yes No

Autism ADHD Cerebral palsy

Who made the diagnosis and when?

Down syndrome Other:

Anxiety disorder

Has anyone (teacher, pediatrician, friend, relative) suggested your child be evaluated for a specific diagnosis? Yes No

What diagnosis?

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Child Strengths Tell us about the child's strengths. What is your child good at? What are his or her interests? What things are going well?

Parent/Guardian Concerns What concerns do you have about your child right now?

Concern Large motor skills (sitting, walking, running, moving around) Small motor skills (using hands and fingers, writing, using utensils) Communication (using words/gestures/signs; expressing wants/needs, understanding others) Thinking, learning, and memory Social skills (making friends, playing with others, showing interest in others) Play skills (using toys, pretend playing) Self-care (feeding himself/herself, getting dressed/undressed, helping around the house) Short attention span Hyperactivity (constantly moving, restless, active) Anxiety (worrying, shy, fearful, problems separating from parents) Repetitive thoughts/behavior (does things over and over, gets "stuck") Repetitive motor mannerisms (rocks, flaps hands, walks on toes, paces) Mood swings/irritability (unpredictable changes between emotions) Tantrums Aggression (hits or bites others) Self-injury (bangs head, hits self, bites self) Sensory issues (over/under-sensitive to sounds, touch, smell) Sleep problems (trouble falling asleep, wakes frequently, still sleeps with adult) Safety problems (runs away, escapes from house, poor awareness of danger, climbs to high spots) Other behavior concerns Please make notes about any concerns selected above.

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Health History

Are any of the following health concerns a problem for the child currently or were a past concern?

Concern

Never

Genetic disorder Head injury/brain problem (hydrocephalus, brain bleed) Seizures Headaches Tics, tremors, or unusual movements Eye or vision problem Ear or hearing problem Dental or tooth problem Heart problem Heart rhythm problems Breathing/lung problem, asthma GI problem: vomiting/reflux/stomach pain Diarrhea (loose, watery stools) Constipation (hard, painful stools) Feeding problem or use of a feeding tube Putting things in mouth that are not food Kidney/bladder/genital problems Bone, joint, or muscle problems Anemia or other blood problems Skin rashes Endocrine or hormone problems Allergies Health concern not listed above If you selected any of the boxes above, please describe...

Currently

In the past

Does your child use any adaptive equipment? Glasses Hearing aids Walker Wheelchair

Communication device

Other:

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What medicines, vitamins, and nutrition supplements does your child take each day?

Medicine name or vitamin/supplement Dose (how many mg

name and brand

and how often)

Reason and who writes prescriptions

Has your child taken medicines to treat chronic health or behavior problems in the past?

Medicine name

Dose (how many mg and how often)

Reason

Does your child eat a special diet or have any food restriction? Please describe.

Has your child ever been admitted to the hospital overnight or had surgery? Age Reason

Has your child had blood drawn to test lead level? If "Yes", was the lead level high?

Is your child up to date on immunizations? Has your child had a hearing test?

If "Yes", at what age?

Yes No Unsure Yes No Unsure Yes No Unsure Yes No Unsure

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